NY Times helmet article misses the mark

Last month. the New York Times ran an article encouraging helmet use by cyclists that was unfortunate in both its tone and the facts it relied upon. 

On tone, the conclusion, which health writer Jane E. Brody decides to start with is overly harsh. 

Riding a bicycle without wearing a properly fitted helmet is simply stupid.

We don't use the s-word in our house, and if we did, we'd have more to back it up then the "High Priestess of Health" does.  The next line "Anyone who does so is tempting fate, risking a potentially life-changing disaster" could just as easily describe a lot of other activities like driving, walking to the store or taking a shower. Yes, there is risk in riding a bike - perhaps more when riding a helmet - but it may be that, due to the dangers of a sedentary lifestyle not riding a bike for want of a helmet is more risky. 

Let's look at some of her facts. 

Even a careful cyclist is likely to crash about once every 4,500 miles

For this she seems to be relying on the Bicycle Helmet Safety Institute (BHSI) (funded by WABA!). But as Robert Hurst points out in the "Art of Cycling" when Ed Burke repeats the claim, they never define "careful" or "crash" or cite the source for this number. Hurst points out that a 1976 survey of cyclists indicated that they suffered some kind of bicycle crash related injury every 9000 miles, and in a 1996 update to that, LAB determined that experienced cyclists - those with an average of 14 years of experience - wiped out every 30,000 miles. So, I'd take issue with the conclusion about how often a careful cyclist is likely to crash. There's no doubt that cyclists crash, but Brody's willingness to rely on a claim of dubious origin, one she repeats without citation, sets the article off on a disturbing path. But now that it's been in the Times, I expect to see it repeated and repeated, until everyone takes it as "common sense." In fact, even before this article the number had already reached that level of repetition.

But then we get to the main source of her claim about the importance of helmet wearing.

one shattering statistic reported by New York City for cyclists in general stands out: 97 percent of cycling deaths and 87 percent of serious injuries occurred to people who were not wearing helmets. 

In this case she's relying on a 2006 New York City Departments of Health and Mental Hygiene, Parks and Recreation, Transportation, and the New York City Police Department study. It is a pretty shattering statistic. It also doesn't mean what she thinks it does. 

For one thing, according to that same study only 74% of all fatal crashes involved a head injury. So somehow not wearing a helmet is also causing deaths that don't involve a head injury.  Even if we assume that every head injury death involved an unhelmeted cyclist (which is a ludicrous assumption), it would mean that 88% of non-head injury deaths also involve an unhelmeted cyclists. And since helmet wearing rates are, by most estimates, higher than 12%, it would somehow imply that cyclists who don't wear helmets are more likely to die from crashes involving head injuries AND those that don't. 

The reason why the percentage is so high, is vast misreporting. As helmet researcher Dr. Richard Keatinge points out:

The figures for dead cyclists are based on the U.S. Department of Transportation's Fatality Analysis Reporting System (FARS). The forms used by FARS do not in general have a convenient box for recording helmet use, which if done at all is done in free text. Thus data entry does not record helmet use accurately after fatalities, and many deaths where helmets were in fact worn will be recorded as "helmet not used"

And cyclehelmets.org expands on this

California data from the StateWide Integrated Traffic Records System (SWITRS) indicates that at least 13.2% of fatally injured bicyclists were using a helmet during the period 1994-98 (since SWITRS combines 'unknowns' and 'not used' into a single category, the helmet use rate is actually a minimum estimate and could be much higher, depending upon the relative number of true 'unknowns' and how biased the distribution might be) (Cal Highway Patrol), but only 3.4% supposedly were doing so according to FARS

Continuing to rely on BHSI, Brody also states that

Head injuries account for three-fourths of the roughly 700 bicycle deaths that occur each year nationwide, and helmets can prevent or reduce the severity of these injuries in two-thirds of cases. This protection holds even in crashes with motor vehicles, researchers from the University of Washington in Seattle reported as long ago as 2000, a statistic verified many times since.

This stat comes from a 1999 review, updated in 2006. But in contradiction to her claim about how often it has been verified, that review has itstead been criticized because the reviewers mostly included studies that were the work of the reviewers themselves, and because they omitted studies that contradicted their own. 

As part of his re-analysis of Attewell, Glase and McFadden, 2001, Elvik, 2011 considered the same studies used in the Cochrane Review and also more recently published studies. Later studies show no net benefit from helmets with regard to injuries to the head, face and neck.

She then notes that she has, in the past, often ridden without a helmet, but no more because she was in a crash where she was wearing a helmet and hit her head, and those suffering a concussion with memory loss, her "helmet prevented a serious brain or facial injury." Which is a claim she can't possibly back up. We simply don't know what would've happened without a helmet. And if she had a standard bicycle helmet, it's hard to imagine how that would have prevented facial injury. I was in a crash in January, and I suffered a serious facial injury despite the fact that I was wearing a helmet. 

She then promises to "never again mount a bicycle without the helmet on my head where it belongs". That's likely a good idea. But it's a long way from declaring that anyone who chooses not to is "simply stupid." And it's certainly not a reason to advocate for adult bicycle helmet laws, as she seems to do. The rest of the article, about how to buy and fit a helmet is fine, and she would've been better off focusing on that. 

Comments

[Smedley Burkhart]

Ms. Brody's research tends to be superficial, which seems related to the "health column" format she works in.

I find it discouraging that general writers on this topic love the lousy epidemiology, but ignore the burgeoning literature on the biomechanics and pathology of traumatic brain injury. As most here are aware, helmets mitigate point loading of the skull, preventing fractures. Skull fractures can lead to rapid death from tearing of arteries and "epidural" blood accumulation with pressure on the brain. However, it is also the informed consensus that helmets are of minimal value in mitigating concussion, a much more common result of bicycle accidents. This fact will never be reflected in the death statistics.

I have crashed a few times and wear a helmet because of the purely subjective sense of security it gives me and my family. It did once come in quite handy years ago, when I was forced off the road and set upon by a frisky gang of young men and I will certainly wear it to my next fistfight.

[DE]

I also wish to wear a helmet to all of my upcoming fistfights!

[Crickey]

A nearly universal fallacy is that helmets prevent concussions. While they almost certainly ameliorate other head injuries, they do virtually nothing to prevent concussions.

[Crickey]

Also, similar story on facial injury while wearing a helmet.

[DaveS]

BHSI was launched by WABA, but they state they're funded by consumers. Nitpicky, I know, but funding for any of this is scarce so it's important to keep the accounting straight.

[DE]

I hear people all the time say that they had an accident and got a concussion*, but thank god they were wearing their helmet or it would have been worse so that's why they always wear one. Well, maybe. You did get a concussion, after all, so how effective was it really? But maybe you avoided a cranial fracture, which of course is a very good to avoid. I'm glad folks wear them, but I think it gives a false sense of security and safety, and calling those who sometimes chose not to wear one stupid is, well, stupid.

*Including my GF. Her immediate post-accident confusion and short-term memory loss was the only time I've ever been smarter than her (although I did let her talk me out of calling 911, so I still wasn't that smart).

[Roo_Beav]

What always grinds my gears is people who slap on a helmet and then bike recklessly - riding against traffic, running red lights/stop signs when there is active traffic, etc. The helmet doesn't protect against stupidity.

Sometimes I see people riding with a helmet on without using the chin strap or people who ride with a helmet dangling from their handlebars or backpack.

My theory is that drivers think bikers are stupid for not wearing a helmet, so they drive more carefully around unhelmeted ones.

I rather avoid a collision than mitigate one.

[DE]

"people who ride with a helmet dangling from their handlebars or backpack"

Hi there, that was me: hot afternoons when the morning was chilly. And yes, I have received comments. Questionable perhaps, but choice is a beautiful thing.

[Smedley Burkhart]

I do miss riding helmetless. Every now and then I forget mine and wonder why I feel so good. On the other hand, I have the medical letters after my name and am supposed to know something academic about TBI. The irony would be simply too rich if I got severely tumbled while practicing unprotected bicyclism.

[Crickey]

The worst part about it is that people think these represent a safe design. They represent a certain approach toward helmet design that stopped evolving 20 years ago. Better designs that provide real protection are possible, and nothing's being done out of the false sense that the existing helmet designs are good enough.

[contrarian]

To follow onto Crickey's comments, helmets provide limited protection because they were designed to provide limited protection. Go look up the standards for bike helmets, they are minimal. They basically provide protection from low-speed falls. They're good for kids and others learning to bike, because falls are common when starting out. They shouldn't be expected to provide any protection in a collision with an automobile, because they're not designed to.

A bike helmet that was designed to protect your head at adult cycling speeds, and in collisions with cars, would look and feel like a motorcycle helmet.

[contrarian]

I was really disappointed with this article and I'm glad WashCycle has taken it on. The NYTimes is normally an excellent paper, this article is not up to their usual standards. What I particularly like about the Times is that even the parts of the paper that other papers consider throw-away -- like travel, style and health -- are well-written and well-researched. That's why this piece was doubly disappointing.

[washcycle]

"Sometimes I see people riding with a helmet on without using the chin strap"

I have a theory that the helmets MPD buys for its bike cops do not have functioning chin straps which is why none of them buckle them.

"or people who ride with a helmet dangling from their handlebars or backpack."

I think of that City Paper cover photo. (https://www.washingtoncitypaper.com/news/article/13036951/what-do-dc-cyclists-have-against-bike-helmets).I think that guy wrote in and said he wears his helmet when he races but not when he's just riding around. Seems reasonable.

"My theory is that drivers think bikers are stupid for not wearing a helmet, so they drive more carefully around unhelmeted ones."

Well, there was that study in the UK that determined that drivers pass closer to a helmeted cyclist than unhelmeted one. But I think it was a pretty small difference, and I don't think it's been repeated enough for me to give it too much validity.

[DE]

I occasionally see people riding a bike with a motorcycle-style helmet. And I think (1) that would provide some actual protection; (B) that would be really hard on the neck and shoulders on anything but a short ride; (III) you really couldn't use your peripheral vision very well, which is more important on a bike than a motorcylce because of the lack of mirrors; and (iv) what would that do to your neck, torsionally, in an accident.

Regarding iv, perhaps motorcycle helmets are designed with smoother surfaces with less angular material to catch on things in an accident. It's not something I've ever researched.

[Doug]

I'll add the following, unverified stat:

100 percent of motorist and pedestrian deaths and 100 percent of serious injuries occurred to people who were not wearing helmets.

[Smedley Burkhart]

The bike helmet concept is up against serious constraints on weight, size, and heat retention. Other than the logical, but pragmatically dubious, MIPS concept of allowing some rotational slip between the head and the helmet shell, and that airbag collar contraption, I'm aware of nothing out there. Any "improvement" might reduce the acceptability of helmets.

And we are stuck with speculation and anecdote. The idea of getting any sort of meaningful signal in a clinical trial is hopeless and we are already bad at doing comparative effectiveness testing, even among drugs under clinical conditions.

There are risks to cycling and no one should kid themselves about them. As everyone says, mitigation should focus on the fixable stuff like infrastructure and behavior.

I face the same thing with offshore racing: If I fall off the boat in the middle of the night, do I want to be dragged to death by my tether in seconds or say bye-bye to the boat and float for a few days before I die? The best idea, it turns out, is to learn how to stay on the boat.

[Crickey]

Research indicates the air bag concept is the way to go here. Those moaning about bike helmets ought to be pushing to have these devices be tested and approved for sale here. These helmets are not perfect, but the designs would get better, and costs drop, if they were available in the mass market here.

https://engineering.stanford.edu/magazine/article/air-bag-bike-helmet-could-protect-against-concussion

[Michael Neubert]

Laws that outlaw adults from riding bicycles without helmets show little evidence of helping the overall safety situation - the usual counterargument is that cyclist safety results from having more cyclists in traffic. Unfortunately laws requiring helmets for adults reduces interest in cycling and reduces further the likelihood of getting to enough cyclists on the road to change the mindset of motorists, who are the main problem for serious accidents after all.

I have been commuting for about 20 years, 20 miles round trip most days. Early in that time I and several others came upon a woman who had been sideswiped by a car and fallen head first into the curb, splitting her helmet in half lengthwise. Amazingly she was conscious and even able to tell us that she wanted to ride home. Her pupils gave her away and someone called 911 - concussion. Even if I can't be sure that the helmet saved her life, I'm pretty sure it saved her from a lot more of an unpleasant injury than she had. So when I plan to ride in traffic much or ride at what passes for high speed for me I wear one. But I do so knowing it just helps and isn't a cure-all.

But if I'm riding a mile to the nearby grocery store entirely on a trail riding an old bike at 8 mph, why do I need a helmet?

[Jack]

Exaggerating about the benefits of helmets is probably a good thing as long as they don't try to pass mandatory helmet laws.

There's a counter-intuitive argument that going without a helmet might be safer because people with helmets are more afraid of crashing, so they ride more carefully. That effect only works if people think it's dangerous to ride without a helmet.

[Jack]

I was glad I was wearing a helmet when:
- My head hit a low hanging tree limb while I was riding on the shoulder
- I tripped in my bike shoes and fell head first into a door frame
- My handlebars didn't have room for a headlight